Better late than never? Experience with intravenous pamidronate treatment in patients with low bone mass or fractures following cardiac or liver transplantation

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Bone Disease and Liver Transplantation: A Review

Liver transplantation is currently the most effective and almost routine treatment for chronic and acute liver diseases. The survival of transplanted patients has increased exponentially, which has led to more knowledge of the long-term complications secondary to the underlying pathology or the various treatments that must be followed. Bone metabolic disease is a chronic complication of liver transplantation that inhibits quality of life. The factors that contribute to the development of bone disease are different according to the various etiologies of liver damage. All patients should be examined for osteoporosis risk factors because the incidence of new fractures in transplant patients is higher during the first year after transplantation, reflecting the greater bone loss during this time. This article outlines a proposal for a treatment algorithm; we propose that pharmacologic therapy in patients post liver transplant should first consider the diagnosis of osteoporosis by bone mineral density, the patient's personal and family history of spine and femoral neck fractures, and the use glucocorticoids (dose and time) until a tool is available that allows the best estimation of the fracture risk in this population of patients.

Effect of neridronate in osteopenic patients after heart, liver or lung transplant: a multicenter, randomized, double-blind, placebo-controlled study

BACKGROUND

Transplantation (Tx) is an effective therapeutic option in patients with end-stage organ failure and osteoporosis and related fractures are a recognized complication in these patients. Aim of this study was to evaluate the efficacy of neridronate in patients with reduced bone mass after Tx of the heart, liver or lung.

METHODS

In this multicenter randomized double-blind controlled trial (RCT), 22 patients were treated with neridronate (25 mg i.m./month) and 17 received placebo. All patients received daily oral calcium (500 mg) and vitamin D (400 IU). Dual-energy X-ray absorptiometry (DXA) was evaluated at 0, 6 and 12 months and markers of bone turnover at 0, 3, 6, 9 and 12 months.

RESULTS

Thirty-nine patients (11 heart Tx, 21 liver Tx, 7 lung Tx), aged 49.3±9.1 years, with a T-score <-2.0 SD at lumbar spine or femoral level were included. In neridronate-treated patients, a significant increase in lumbar bone mineral density (BMD) was observed after 12 months vs. placebo control (0.92±0.13 g/cm² vs. 0.84±0.08 g/cm²; P=0.005). Femur and hip BMD remained unchanged between groups. Total alkaline phosphatase, bone alkaline phosphatase and beta-cross-laps significantly decreased over the 12 months in neridronate-treated patients vs. placebo, respectively (107.4±74 U/L vs. 157.6±107.1 U/L, P=0.002; 5.7±3.3 µg/L vs. 11.7±4.3 µg/L, P<0.001 and 0.25±0.13 ng/mL vs. 0.73±0.57 ng/mL, P<0.001). No difference was observed between neridronate and placebo groups regarding safety profile.

CONCLUSIONS

This is the first RCT that demonstrates the efficacy of neridronate in increasing bone density and reducing bone turnover in organ Tx recipients with significant skeletal morbidity.

Bone disease following solid organ transplantation: A narrative review and recommendations for management from The European Calcified Tissue Society

INTRODUCTION

Solid organ transplantation is an established therapy for end-stage organ failure. Both pre-transplantation bone disease and immunosuppressive regimens result in rapid bone loss and increased fracture rates.

METHODS

The European Calcified Tissue Society (ECTS) formed a working group to perform a systematic review of existing literature on the consequences of end-stage kidney, liver, heart, and lung disease on bone health. Moreover, we assessed the characteristics of post-transplant bone disease and the skeletal effects of immunosuppressive agents and aimed to provide recommendations for the prevention and treatment of transplantation-related osteoporosis.

RESULTS

Characteristics of bone disease may differ depending on the organ that fails, but patients awaiting solid organ transplantation frequently depict a wide spectrum of bone and mineral abnormalities. Common features are a decreased bone mass and impaired bone strength with consequent high fracture risk, all of which are aggravated in the early post-transplantation period.

CONCLUSION

Both the underlying disease leading to end-stage organ failure and the immunosuppression regimens implemented after successful organ transplantation have detrimental effects on bone mass, quality and strength. Given existing ample data confirming the high frequency of bone disease in patients awaiting solid organ transplantation, we recommend that all transplant candidates should be assessed for osteoporosis and fracture risk and, if indicated, treated before and after transplantation. Since bone loss in the early post-transplantation period occurs in virtually all solid organ recipients and is associated with glucocorticoid administration, the goal should be to use the lowest possible dose and to taper and withdraw glucocorticoids as early as possible.

Bone Diseases in Patients with Chronic Liver Disease

Osteoporosis is a frequently observed complication in patients with chronic liver disease, particularly liver cirrhosis and cholestatic liver diseases. In addition, osteoporosis is critical in patients receiving a liver transplant. Nevertheless, few studies have evaluated bone diseases in patients with more frequently observed chronic liver disease, such as chronic viral hepatitis, nonalcoholic fatty liver disease and alcoholic liver disease. Osteoporosis is a disease caused by an imbalance in the activities of osteoblasts and osteoclasts. Over the last few decades, many advances have improved our knowledge of the pathogenesis of osteoporosis. Importantly, activated immune cells affect the progression of osteoporosis, and chronic inflammation may exert an additional effect on the existing pathophysiology of osteoporosis. The microbiota of the intestinal tract may also affect the progression of bone loss in patients with chronic liver disease. Recently, studies regarding the effects of chronic inflammation on dysbiosis in bone diseases have been conducted. However, mechanisms underlying osteoporosis in patients with chronic liver disease are complex and precise mechanisms remain unknown. The following special considerations in patients with chronic liver disease are reviewed: bone diseases in patients who underwent a liver transplant, the association between chronic hepatitis B virus infection treatment and bone diseases, the association between sarcopenia and bone diseases in patients with chronic liver disease, and the association between chronic liver disease and avascular necrosis of the hip. Few guidelines are currently available for the management of low bone mineral density or bone diseases in patients with chronic liver disease. Due to increased life expectancy and therapeutic advances in chronic liver disease, the importance of managing osteoporosis and other bone diseases in patients with chronic liver disease is expected to increase. Consequently, specific guidelines need to be established in the near future.

Diagnosis and Management of Cirrhosis-Related Osteoporosis

Management of cirrhosis complications has greatly improved, increasing survival and quality of life of the patients. Despite that, some of these complications are still overlooked and scarcely treated, particularly those that are not related to the liver. This is the case of osteoporosis, the only cirrhosis complication that is not solved after liver transplantation, because bone loss often increases after immunosuppressant therapy. In this review, the definitions of bone conditions in cirrhotic patients are analyzed, focusing on the more common ones and on those that have the largest impact on this population. Risk factors, physiopathology, diagnosis, screening strategies, and treatment of osteoporosis in cirrhotic patients are discussed, presenting the more striking data on this issue. Therapies used for particular conditions, such as primary biliary cirrhosis and liver transplantation, are also presented.

The risk of osteoporosis in patients with liver cirrhosis: a meta-analysis of literature studies

OBJECTIVE

Data about the association between cirrhosis and osteoporosis are contrasting. Thus, we have performed a meta-analysis of literature studies on this topic.

DESIGN

MEDLINE, Cochrane library, EMBASE, Scopus and Web of Science databases have been searched to retrieve all articles of interest. Data on prevalence of osteoporosis, bone mineral density (BMD) and bone turnover laboratory parameters were compared among cirrhotic patients and control subjects without cirrhosis.

PATIENTS

Studies on patients with liver cirrhosis screened for the presence of osteoporosis were included.

RESULTS

Six case-control studies (372 cirrhotic patients and 1579 controls) were included. The prevalence of osteoporosis was higher in cirrhotic patients than in controls (34·7% vs 12·8%, OR: 2·52, 95%CI: 1·11, 5·69; P = 0·03, I(2) = 81%; P = 0·005). Accordingly, a reduced lumbar spine BMD (MD: -0·13, 95%CI: -0·24, -0·02; P = 0·02, I(2) = 93%; P < 0·00001) and z-score (MD: -1·06, 95%CI: -1·79, -0·34; P = 0·004, I(2) = 95%; P < 0·00001) were found in cirrhotic patients as compared with controls. In contrast, no significant differences were reported in femoral neck BMD and z-score. Interestingly, bone turnover laboratory parameters widely confirmed these results showing higher levels of ALP and D-Pyr, accompanied by reduced levels of IGF-1, PTH and 25-OH-D in cirrhotic patients as compared with controls.

CONCLUSIONS

Despite the high heterogeneity among studies, data showed an increased prevalence of osteoporosis in patients with cirrhosis. This information suggests the need of an accurate screening of bone mineral density in patients with liver cirrhosis to plan an adequate osteoporosis management.

Current Status of Research on Osteoporosis after Solid Organ Transplantation: Pathogenesis and Management

Improved survival following organ transplantation has brought to the forefront some long-term complications, among which osteoporosis and associated fractures are the major ones that adversely affect the quality of life in recipients. The pathogenesis of osteoporosis in transplant recipients is complex and multifactorial which may be related to increased bone resorption, decreased bone formation, or both. Studies have shown that the preexisting underlying metabolic bone disorders and the use of immunosuppressive agents are the major risk factors for osteoporosis and fractures after organ transplantation. And rapid bone loss usually occurs in the first 6–12 months with a significant increase in fracture risk. This paper will provide an updated review on the possible pathogenesis of posttransplant osteoporosis and fractures, the natural history, and the current prevention and treatment strategies concerning different types of organ transplantation.

Bone density in heart or lung transplant recipients--a longitudinal study

BACKGROUND

Osteoporosis is prevalent among heart or lung transplant (HLT) candidates. Bone loss is common posttransplant, with an associated increase in fracture risk. There is a lack of consensus regarding optimal management of bone health in HLT recipients. We report bone health data in a cohort of HLT recipients before and after transplantation and make recommendations for management.

METHODS

Patients over the age of 20 who had a heart or lung transplant between 2000 and 2011 were identified from the New Zealand HLT Service database, and demographic data, immunosuppressive regimens, bisphosphonate use, and serial bone mineral density (BMD) data were extracted.

RESULTS

Pretransplant BMD was available in 52 heart and 72 lung transplant recipients; 30 and 42, respectively, also had posttransplant BMD data. Pretransplant osteopenia or osteoporosis prevalence were 23% and 8% for heart candidates and 36% and 31% for lung candidates. Posttransplant, BMD decreased significantly at the femoral neck but not at the lumbar spine in the first year, with subsequent stabilization particularly in the presence of bisphosphonate use. Pretransplant BMD was the major predictor for developing osteopenia or osteoporosis after transplantation.

CONCLUSION

A significant proportion of HLT recipients have osteopenia or osteoporosis pretransplant, and this persists posttransplant. Pretransplant BMD is an important predictor of subsequent osteopenia or osteoporosis development, allowing risk stratification and targeted intervention.

Management of osteoporosis in liver disease

Osteoporosis resulting in a high risk for fracture is a common complication in patients with liver disease, particularly in those with chronic cholestasis and with end-stage cirrhosis. The pathogenesis of bone loss in liver patients is poorly understood but it mainly results from low bone formation as a consequence of cholestasis or the harmful effects of alcohol or iron on osteoblasts. Increased bone resorption has also been described in cholestatic women with advanced disease. The management of bone disease in liver patients is addressed to reduce or avoid the risk factors for osteoporosis and fracture. Bisphosphonates associated with supplements of calcium and vitamin D are safe and effective for increasing bone mass in patients with chronic cholestasis and after liver transplantation, though no clear achievements in descreasing the incidence of fractures have been described, probably because of the low number of patients included in the therapeutic trials. Randomized studies assessing bisphosphonates in larger series of patients, the development of new drugs for osteoporosis and the improvement in the management of liver transplant recipients may change the future.

Osteoporosis following organ transplantation: pathogenesis, diagnosis and management

Organ transplantation has become popular for the management of various chronic illnesses. With the advent of modern immunosuppressive treatments, the longevity of transplant recipients has increased. Consequently, morbid complications such as osteoporosis and bone fractures are seen at an increasing frequency in this population. In most transplant recipients, bone mineral density (BMD) falls shortly after transplantation. However, bone fracture rate plateaus in all except for post-renal transplant patients. Although the underlying pathophysiologic mechanism for this difference is not fully understood, potential mechanisms for sustained bone loss in renal transplant recipients may be persistent phosphorus wasting and defective bone mineralization. Current treatment regimens are based on studies in a small numbers of subjects with BMD as the primary outcome. Although BMD is recognized as a gold standard in the assessment of bone fracture risk, to date, its association with bone fracture risk in the general post-transplant population is not robust. Therefore, randomized controlled trials with bone fracture as the primary end point are crucial. The development of noninvasive bone markers in distinguishing bone turnover and bone mineralization status is also pivotal since skeletal lesions are heterogeneous in various organ transplantations. The elucidation of these underlying skeletal lesions is necessary for the consideration of selective treatment in this population.

Liver and bone

Osteoporosis is a frequent complication in patients with chronic liver disease, especially in end-stages and in cases with chronic cholestasis, hemochromatosis and alcohol abuse. The problem is more critical in transplant patients when bone loss is accelerated during the period immediately after transplantation, leading to a greater incidence of fractures. Advanced age, low body mass index and severity of the liver disease are the main risk factors for bone disease in patients with cholestasis. Mechanisms underlying osteoporosis in chronic liver disease are complex and poorly understood, but osteoporosis mainly results from low bone formation, related to the effects of retained substances of cholestasis, such as bilirubin and bile acids, or to the effects of alcohol on osteoblastic cells. Increased bone resorption has also been described in cholestatic women with advanced disease. Although there is no specific treatment, bisphosphonates associated with supplements of calcium and vitamin D are effective for increasing bone mass in patients with chronic cholestasis and after liver transplantation. The outcome in reducing the incidence of fractures has not been adequately demonstrated essentially because of the low number of patients included in the therapeutic trials. Randomized studies assessing bisphosphonates in larger series of patients, the development of new drugs for osteoporosis and the improvement in the management of liver transplant recipients may change the future.

Effect of bisphosphonates on bone mineral density in liver transplant patients: a meta-analysis and systematic review of randomized controlled trials

SUMMARY

Bone mineral density (BMD) loss after liver transplantation (LT) results in considerable morbidity with the increased risk of fractures. Data on the efficacy of bisphosphonate use in post LT patients is scarce. This meta-analysis aims to summarize the results from published randomized controlled trials (RCTs) on the topic of interest. Electronic databases were searched to identify relevant publications. A total of 157 articles were identified and reviewed. Individual authors were contacted from relevant RCTs to obtain individual patient data where necessary to uniformly quantify BMD values post LT pre- and post LT. A total of six RCTs were used for final data extraction. (i) Lumbar Spine: In 364 patients (six studies, 182 in intervention and control groups each), bisphosphonate therapy improved BMD by 0.03 g/cm(2) (95% C.I. 0.01-0.05 g/cm(2); P = 0.02) at 12 months post LT. (ii) Femoral neck: In 268 patients (four studies, 130 bisphosphonate, 138 control), bisphosphonate use did not result in a statistically significant change in BMD at the end of 1 year. None of the studies noted serious adverse effects related to bisphosphonate administration. Data on incident fractures could not be pooled because of heterogeneity. Bisphosphonate therapy during the first year in LT recipients appears to reduce accelerated bone loss and improve bone mineral density at the lumbar spine.

Pamidronate in the prevention of bone loss after liver transplantation: a randomized controlled trial

Rapid bone loss and high rates of fractures occur following liver transplantation. To analyze the effect of intravenous pamidronate on bone loss after liver transplantation. A randomized, double-blind, placebo-controlled study was performed. Seventy-nine patients were randomized to two groups of treatment: the pamidronate group (n = 38) was treated with 90 mg/IV of pamidronate within the first 2 weeks and at 3 months after transplantation; the placebo group (n = 41) received glucose infusions at the same time points. All patients received calcium and vitamin D. Bone mineral density (BMD) at the lumbar spine (L(2)-L(4)) and proximal femur using dual energy X-ray absorptiometry and also spinal X-rays were performed before, and at 6 and 12 months after liver transplantation. Biochemical and hormonal determinations were performed previous to transplantation, at 24 h before and after treatment, as well as at 6 and 12 months after liver transplantation. At 12 months after transplantation, there were significant differences in lumbar BMD changes (6 months: pamidronate 1.6% vs. placebo 0.8%, P = NS; 12 months: pamidronate 2.9% vs. placebo 1%, P < 0.05). Femoral neck BMD decreased in the pamidronate- and placebo groups during the first 6 months (6 months: pamidronate -3.1% vs. placebo -2.9%, P = NS; 12 months: pamidronate -3.2% vs. placebo -3.1%, P = NS). BMD at the trochanter remained stable in the pamidronate group, whilst a reduction was observed in the placebo group at 6 months (6 months: pamidronate -0.7% vs. placebo -3.7%, P < 0.05; 12 months: pamidronate -0.5% vs. placebo -1.2%, P = NS). Moreover, no significant differences in the incidence of fractures, serum parathyroid hormone and serum 25-hydroxyvitamin D values between both groups were found. Pamidronate did not increase the risk of serious adverse events. The results of this study show that 90 mg of intravenous pamidronate within the first 2 weeks and at 3 months following liver transplantation preserve lumbar bone mass during the first year, without significant adverse events. However, pamidronate does not reduce bone loss at the femoral neck and furthermore it does not reduce skeletal fractures.

Collapsing focal segmental glomerulosclerosis in a liver transplant recipient on alendronate

We describe a case of collapsing focal segmental glomerulosclerosis and severe kidney dysfunction in a liver transplant recipient after the initiation of alendronate for osteopenia. In view of the increasing incidence of chronic kidney disease in long-term liver transplant patients, bisphosphonates need to be used with caution in these patients. The usefulness of bisphosphonates for the prevention of early bone loss after liver transplantation is increasingly reported. However, there is little information on the safety and efficacy of these drugs when used in the later stages of liver transplant, particularly in the presence of chronic kidney disease. Bisphosphonates are excreted unchanged via the kidneys after reaching the systemic circulation. Some cases of severe kidney injury, in particular collapsing focal segmental glomerulosclerosis, have been described that are associated with the use of pamidronate. Alendronate, a widely used bisphosphonate in transplant patients, has not been related to kidney toxicity. We describe a case of collapsing focal segmental glomerulosclerosis and severe kidney dysfunction in a liver transplant recipient soon after the initiation of alendronate for osteopenia. Possible pathogenetic mechanisms are discussed. In view of the increasing incidence of chronic kidney disease in long-term liver transplant patients, bisphosphonate need to be used with caution in patients with a low glomerular filtration rate.

Transplantation osteoporosis

In the past two decades, there has been a rapid increase in the number of organ transplanted worldwide, including Brazil, along with an improvement in survival and quality of life of the transplant recipients. Osteoporosis and a high incidence of fragility fractures have emerged as a complication of organ transplantation. Many factors contribute to the pathogenesis of osteoporosis following organ transplantation. In addition, most patients have some form of bone disease prior to transplantation, which is usually related to adverse effects of end-stage organ failure on the skeleton. This chapter reviews the mechanisms of bone loss that occur both in the early and late post-transplant periods, as well as the features specific to bone loss after kidney, lung, liver, cardiac and bone marrow transplantation. Prevention and treatment for osteoporosis should be instituted prior and in the early and late phase after transplantation, and will also be addressed in this article.

Use of intravenous bisphosphonates in osteoporosis

Bisphosphonates, which are potent bone resorption inhibitors, currently are the mainstay of treatment for osteoporosis. Antifracture efficacy has been demonstrated for at least three nitrogen-containing bisphosphonates in oral formulations that are designed to be administered in weekly or monthly dosing regimens. Frequent reports of adverse events, primarily related to the upper gastrointestinal tract, and the strict dosing schedule necessary for oral bisphosphonate therapy are considered the major reasons for disappointing adherence to therapy. New intravenous formulations have been developed that allow dosing at very long intervals, thus avoiding the gastrointestinal complications associated with oral bisphosphonates and, it is hoped, improving compliance, particularly for patients who are intolerant of oral bisphosphonates or have contraindications to their use. This alternative approach holds promise for improved outcomes of osteoporosis treatment and ultimately for reduced health care costs related to caring for people with fragility fractures.

Review article: medical management of the liver transplant recipient - a primer for non-transplant doctors

BACKGROUND

Survival 10 years after orthotopic liver transplantation now approaches 65%. Consequently, community doctors must manage the metabolic and neoplastic complications of orthotopic liver transplantation in an ageing population.

AIMS

To review common sources of morbidity and mortality in long-term orthotopic liver transplantation recipients, and to make evidence-based recommendations regarding their management.

METHODS

Pertinent studies and reviews were identified by literature search through PubMed. Where evidence-based recommendations could not be gleaned from the literature, expert opinion was obtained from syllabi of national meetings.

RESULTS

The two most common causes of morbidity and mortality in orthotopic liver transplantation recipients are atherosclerotic vascular disease and de novo malignancy. The pathogenesis of many complications begins before orthotopic liver transplantation, and many are potentially modifiable. Most complications, however, can be directly ascribed to immunosuppressive agents. Despite improvements in our understanding of the pathogenesis and epidemiology of the metabolic and neoplastic complications of orthotopic liver transplantation, remarkably few randomized-controlled studies exist to define their optimal management.

CONCLUSIONS

Orthotopic liver transplantation recipients experience and succumb to the same afflictions of old age as non-transplant patients, but with greater frequency and at an earlier age. Most recommendations regarding surveillance for, and treatment of, medical complications of orthotopic liver transplantation remain based upon expert opinion rather than evidence-based medicine.

Pamidronate and osteoporosis prevention in liver transplant recipients

Osteoporosis is a common complication in patients with end-stage liver disease and after orthotopic liver transplantation (LT), with resulting increasing fracture rate. In this study, we investigated the role of treatment with pamidronate in preventing further bone loss after LT. Eighty-five patients with end-stage liver disease were included in the study. Pamidronate 30 mg was given intravenously every 3 months after LT for the duration of 1 year to 43 patients with osteopenia or osteoporosis prior LT. The remainders served as controls. All patients received a supplementation of calcium and vitamin D. Bone mineral density (BMD) at the lumbar spine and the femoral neck, and markers of bone metabolism were measured before and 12 months after LT. Sixty-two BMD were available at 12 months; only paired BMD were evaluated. A significant increase in lumbar spine BMD was observed in pamidronate treated patients. No change was evident in controls. Femoral neck BMD decreased in both treated and untreated patients. Osteocalcin serum levels and deoxypyridinoline urinary excretion were significantly reduced by treatment. Our study suggests that pamidronate decreases bone turnover and is effective in preventing the course of bone loss after LT, however the efficacy, at the dosage regimen employed and in a follow-up of 12 months, appears to be limited to trabecular bone, with no effect on the cortical structure of the femur.

The Prevention of Bone Fractures After Liver Transplantation: Experience With Alendronate Treatment

OBJECTIVE

The aim of this study was to prevent fractures in the first postoperative year.

METHODS AND PATIENTS

We studied 59 patients (48 men, 11 women) aged 42.6+/-11.4 years, who underwent liver transplantation. All patients received oral alendronate 70 mg weekly and calcium 1 g and calcitriol 0.5 mug daily. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the lumbar spine and proximal femur at baseline as well as at 6 and 12 months after transplantation for comparison with an historical control group (n=31). Spinal radiographs were obtained to assess vertebral fractures at the same time. Additionally, serum osteocalcin, serum parathyroid hormone (PTH), urinary deoxypyridinoline (DPD), and biochemical parameters were determined every 3 months.

RESULTS

At baseline, femoral total BMD of men was significantly greater than that of women (P<.05, .85+/-.1 vs .74+/-.1). A significant increase in BMD was observed at 12 months (P<.05), no patient developed a bone fracture. Comparison analysis of genders showed that there was a significant difference in favor of men (P<.05). The lumbar BMD, neck T-, and Z-scores were significantly higher among patients treated with alendronate than historical controls (P<.05). After 3 months, serum PTH was increased and serum osteocalcin and urinary DPD were reduced. No severe side effects from alendronate treatment were observed during the study.

CONCLUSION

A direct sign of the success of our study was no fracture observed during the first postoperative year. Alendronate should be considered for patients with low bone mass after liver transplantation.

Effects of alendronate on bone mineral density and bone metabolic markers in patients with liver transplantation

INTRODUCTION

The purpose of this study was to evaluate the effects of alendronate (ALN) on bone mineral density (BMD) and bone turnover markers in patients with orthotopic liver transplantation (OLT).

METHODS

In the prospective, controlled, open study with 24 months of follow-up, 98 patients with OLT were randomised to receive ALN 70 mg weekly or no ALN; calcium (Ca) 1,000 mg daily and 0.5 mcg calcitriol daily were provided to all patients. Lumbar spine (LS) and hip BMDs were measured at 6-month intervals by dual-energy X-ray absorptiometry (DEXA). Spinal radiographs were obtained to assess vertebral fractures. Additionally, bone turnover markers, serum parathyroid hormone (PTH) and biochemical parameters were determined every 3 months.

RESULTS

Compared with the control group, the ALN group showed significant increases in BMD of the LS (5.1+/-3.9% vs 0.4+/-4.2%, p<0.05 at 12 months, 8.9+/-5.7% vs 1.4+/-4.9%, p<0.05 at 24 months), femoral neck (4.3+/-3.8% vs -1.1+/-3.1%, p<0.05 at 12 months, 8.7+/-4.8% vs 0.6+/-4.5%, p<0.05 at 24 months) and total femur (3.6+/-3.8% vs -0.6+/-4.0%, p<0.05 at 12 months, 6.2+/-3.8% vs 0.3+/-4.6%, p<0.05 at 24 months). In the ALN group, osteocalcin and urinary deoxypyridinoline (DPD) decreased significantly at the sixth month, with no further change, by -35.6% and -63.0%, on average, respectively (p<0.05). In the control group, a significant increase in biochemical markers of bone turnover was observed in comparison to baseline values (p<0.05). PTH increased within reference levels without a difference between groups. Two nonvertebral fractures (4.2%) and nine vertebral fractures (18.8%) in the control group and three vertebral fractures (6.8%) in the ALN group occurred during the follow-up. The weekly ALN was well tolerated, and no severe side effects occurred.

CONCLUSION

This is the first randomised study including a control group to demonstrate that weekly ALN was able to significantly increase BMD in patients with OLT when compared with Ca and calcitriol alone. However, ALN did not appear to offer protection against fractures.

Alendronate in combination with calcium and vitamin D prevents bone loss after orthotopic liver transplantation: a prospective single-center study

Bone loss is a common complication in patients before and after liver transplantation (LT). The aim of this study was to investigate the efficacy of prophylactic treatment with bisphosphonates after LT in preventing progressive bone loss in LT patients. We included 136 patients with end-stage liver diseases awaiting LT. Bone mineral density (BMD) (by dual X-ray absorptiometry) and markers of bone metabolism were determined before, and 4, 12, 24, 36, and 48 months after LT. All patients received vitamin D and calcium supplementation before and after LT, those with osteopenia or osteoporosis prior to LT were additionally treated with alendronate following LT. Decreased BMD was seen in a high percentage of patients undergoing LT (osteopenia 48.5%, osteoporosis 23.5%). Reduced BMD before LT was not related to gender, underlying liver disease, or Child-Turcotte-Pugh classification. Body mass index (BMI) prior to LT, however, correlated significantly with the fracture risk. Alendronate prevented the ubiquitously observed bone loss after LT in patients with osteoporosis and osteopenia and, in addition, led to an increase in BMD in patients with osteoporosis within 24 months after LT. In conclusion, our study suggests that alendronate is efficacious in preventing the natural course of bone loss associated with LT.

Osteoporose após transplante de órgãos sólidos

A osteoporose é uma complicação comum após os transplantes de rim, coração, fígado e pulmão. Os esquemas imunossupressores para evitar a rejeição do órgão enxertado após o transplante freqüentemente incluem glicocorticóides, ciclosporina A e tacrolimus, os quais possuem efeitos danosos sobre a homeostase mineral óssea, impostos a um esqueleto já comprometido. Outros fatores que provavelmente contribuem para a patogênese da osteoporose pós-transplante são deficiência de vitamina D, hiperparatireoidismo secundário e hipogonadismo. Medidas para avaliação da saúde óssea antes do transplante deveriam ser realizadas: densitometria mineral óssea, radiografia da coluna, avaliação do nível de vitamina D e dos hormônios gonadais. Todos os pacientes transplantados deveriam ser submetidos à profilaxia da perda óssea. Estudos clínicos sugerem que os bisfosfonatos são os agentes mais promissores para a prevenção e o tratamento da osteoporose pós-transplante.

Bisfosfonatos intravenosos

Bisphosphonates possess a fundamental role in the treatment of bone metabolic diseases. Yet their main limitations are poor oral absorption and gastrointestinal side effects, mainly esophageal irritation. Indeed, oral administration is unpleasant for many patients, and it is difficult in bed-confined subjects. Therefore, intravenous administration of these agents can be very useful in several clinical scenarios, especially to improve the compliance. Recently, it has been showed that intravenous bisphosphonates are very useful to control hypercalcemia of malignancy, and to prevent bone complications related to metastases. Their use has also been analyzed in the prevention of bone disease after organ transplantation. Thus, their application to control Paget's disease of bone is well-known, and probably they could have an important role as antiresorptive agents in postmenopausal and steroidal osteoporosis. We present here a state of the art of the use of intravenous bisphosphonates for the aforementioned disorders.

Management of bone loss after organ transplantation

Organ transplant recipients experience rapid bone loss and high fracture rates, particularly during the early post-transplant period. Early rapid bone loss occurs in the setting of uncoupled bone turnover with increased bone resorption and decreased bone formation. Because there are no clinical factors that reliably predict post-transplant bone loss and fractures in the individual patient, all transplant recipients should be considered candidates for early preventive therapy for osteoporosis. Long-term transplant recipients with densitometric osteoporosis and/or fractures should also receive treatment. Although active metabolites of vitamin D and bisphosphonates have both shown efficacy, data from clinical trials suggest that bisphosphonates are the safest and most consistently effective agents for the prevention and treatment of post-transplantation osteoporosis in adults. Kidney transplant recipients represent a special population, and more research is needed to delineate the risks and benefits of treating bone disease in these patients.

Older age and liver transplantation: a review

Patients older than 60 are undergoing transplantation with increasing frequency. Reports from several transplant centers document that overall short-term patient survival rates in seniors undergoing liver transplantation are comparable to survival rates of younger adults. However, specific subgroups of older patients may not fare as well. Seniors with far-advanced end-stage liver disease are high-risk for liver transplantation and have poor survival rates. In addition, seniors older than 65 have worse outcomes than those who are 60 to 65, and studies have shown increased mortality with increasing age as a continuous variable. On the other hand, the majority of seniors who survive liver transplantation have full or only minimally limited functional status. Preoperative evaluation of older patients for transplantation requires careful screening to exclude cardiopulmonary disease, malignancy, and other diseases of the aged. Paradoxically, seniors may benefit from a senescent immune system, which results in decreased requirements for immunosuppressive drugs, and possibly a lower rate of acute allograft rejection. Despite good overall short-term survival in the elderly, long-term survival may be worse because of an increased rate of long-term complications, such as malignancy and heart disease. In conclusion, although advanced age is a negative risk factor, advanced age alone should not exclude a patient from liver transplantation; however, it mandates thorough pretransplant evaluation and careful long-term follow-up with attention to usual health maintenance issues in the elderly.

Osteoporosis: The dynamic relationship between magnesium and bone mineral density in the heart transplant patient

Osteoporosis is a common, and potentially severe, complication seen in the heart transplant recipient. Frequently there is loss of bone mineral density prior to transplant that begins the downward spiral to fractures of the femoral neck and vertebrae. Multiple factors are responsible for the development of osteoporosis posttransplant. These factors include pretransplant bone mineral loss, use of corticosteroids and cyclosporine posttransplant, and development of persistent hypomagnesemia posttransplant. This article explores the relationship of serum magnesium levels to maintenance of bone mineral density.

Intravenous bisphosphonate therapy for osteoporosis: where do we stand?

The use of oral bisphosphonates, particularly members of the aminobisphosphonate subclass, is well established for the treatment of osteoporosis. In a number of clinical settings, intravenous administration appears to be advantageous. However, current dosing and efficacy data are limited while definitive, long-term trials with some of these agents are ongoing. In this article, we review the available information and discuss the use of these drugs on that basis.